Effect of daily discrimination on naturalistic sleep health features in young adults

OBJECTIVE

Racial inequities in sleep health are well documented and may be partially attributable to discrimination experiences. However, the effects of acute discrimination experiences on same-night sleep health are understudied. We quantified naturalistic discrimination experiences captured using ecological momentary assessment (EMA) and examined whether reporting discrimination on a given day predicted sleep health that night.

METHOD

Participants completed baseline assessments and a 17-day EMA protocol, with text prompts delivered four times daily to collect discrimination experiences. Seven different daily sleep characteristics were ascertained each morning. Discrimination reasons (e.g., because of my racial identity) were reported by participants and categorized into any, racial, or nonracial discrimination. Outcomes included the seven sleep diary characteristics. We fit generalized linear mixed effects models for each sleep outcome and discrimination category, controlling for key covariates.

RESULTS

The analytic sample included 116 self-identified Black and White individuals (48% Black, 71% assigned female at birth, average age = 24.5 years). Among Black participants, race-based discrimination was associated with a 0.5-hr reduction in total sleep time (TST). Among White individuals, nonracial discrimination was associated with a 0.6-hr reduction in TST, an earlier sleep offset, and reduced sleep efficiency (partly attributable to more nighttime awakenings).

CONCLUSIONS

Young adults may sleep worse on nights after experiencing discrimination, and different types of discrimination affect different sleep outcomes for Black and White individuals. Future studies may consider developing treatments that account for different sleep vulnerabilities for people experiencing discrimination on a given day. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Vulvar Cancer, Version 3.2024, NCCN Clinical Practice Guidelines in Oncology

Vulvar cancer is annually diagnosed in an estimated 6,470 individuals and the vast majority are histologically squamous cell carcinomas. Vulvar cancer accounts for 5% to 8% of gynecologic malignancies. Known risk factors for vulvar cancer include increasing age, infection with human papillomavirus, cigarette smoking, inflammatory conditions affecting the vulva, and immunodeficiency. Most vulvar neoplasias are diagnosed at early stages. Rarer histologies exist and include melanoma, extramammary Paget's disease, Bartholin gland adenocarcinoma, verrucous carcinoma, basal cell carcinoma, and sarcoma. This manuscript discusses recommendations outlined in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for treatments, surveillance, systemic therapy options, and gynecologic survivorship.

CHARIOT: a phase I study of berzosertib with chemoradiotherapy in oesophageal and other solid cancers using time to event continual reassessment method

BACKGROUND

Berzosertib (M6620) is a highly potent (IC50  =  19 nM) and selective, first-in-class ataxia telangiectasia-mutated and Rad3-related protein kinase (ATR) inhibitor. This trial assessed the safety, preliminary efficacy, and tolerance of berzosertib in oesophageal cancer (A1 cohort) with RT and advanced solid tumours (A2 cohort) with cisplatin and capecitabine.

METHODS

Single-arm, open-label dose-escalation (Time-to-Event Continual Reassessment Method) trial with 16 patients in A1 and 18 in A2. A1 tested six dose levels of berzosertib with RT (35 Gy over 15 fractions in 3 weeks).

RESULTS

No dose-limiting toxicities (DLTs) in A1. Eight grade 3 treatment-related AEs occurred in five patients, with rash being the most common. The highest dose (240 mg/m2) was determined as the recommended phase II dose (RP2D) for A1. Seven DLTs in two patients in A2. The RP2D of berzosertib was 140 mg/m2 once weekly. The most common grade ≥3 treatment-related AEs were neutropenia and thrombocytopenia. No treatment-related deaths were reported.

CONCLUSIONS

Berzosertib combined with RT is feasible and well tolerated in oesophageal cancer patients at high palliative doses. Berzosertib with cisplatin and capecitabine was well tolerated in advanced cancer. Further investigation is warranted in a phase 2 setting.

CLINICAL TRIALS IDENTIFIER

EU Clinical Trials Register (EudraCT) - 2015-003965-27 ClinicalTrials.gov - NCT03641547.

Serotonin is a common thread linking different classes of antidepressants

Depression pathology remains elusive. The monoamine hypothesis has placed much focus on serotonin, but due to the variable clinical efficacy of monoamine reuptake inhibitors, the community is looking for alternative therapies such as ketamine (neurogenesis theory of antidepressant action). There is evidence that different classes of antidepressants may affect serotonin levels; a notion we test here. We measure hippocampal serotonin in mice with voltammetry and study the effects of acute challenges of escitalopram, fluoxetine, reboxetine, and ketamine. We find that pseudo-equivalent doses of these drugs similarly raise ambient serotonin levels, despite their differing pharmacodynamics because of differences in Uptake 1 and 2, rapid SERT trafficking, and modulation of serotonin by histamine. These antidepressants have different pharmacodynamics but have strikingly similar effects on extracellular serotonin. Our findings suggest that serotonin is a common thread that links clinically effective antidepressants, synergizing different theories of depression (synaptic plasticity, neurogenesis, and the monoamine hypothesis).

NCCN Guidelines® Insights: Cervical Cancer, Version 1.2024

The NCCN Guidelines for Cervical Cancer provide recommendations for all aspects of management for cervical cancer, including the diagnostic workup, staging, pathology, and treatment. The guidelines also include details on histopathologic classification of cervical cancer regarding diagnostic features, molecular profiles, and clinical outcomes. The treatment landscape of advanced cervical cancer is evolving constantly. These NCCN Guidelines Insights provide a summary of recent updates regarding the systemic therapy recommendations for recurrent or metastatic disease.

Patient-Specific 3D CT Images Reconstruction from 2D KV Images Via Vision Transformer-Based Deep-Learning

PURPOSE/OBJECTIVE(S)

In some proton therapy facilities, patient alignment relies on two 2D orthogonal kV images, taken at fixed, oblique angles, as no 3D on-the-bed-imaging is available. The visibility of the tumor in kV images is limited since the patient's 3D anatomy is projected onto a 2D plane, especially when the tumor is behind a high-density structure such as bone. This can lead to a large patient setup error. A solution to this problem is to reconstruct the 3D CT image from the kV images obtained in the treatment position.

MATERIALS/METHODS

An asymmetric autoencoder-like network built with vision-transformer blocks was developed. The data was collected from a head and neck patient: 2 orthogonal kV images (1024X1024 voxels), 1 3D CT with padding (512X512X512) acquired from the in-room CT-on-rails before kVs were taken and 2 digitally-reconstructed-radiograph (DRR) images (512X512) based on the CT. We resampled kV images every 8 voxels and DRR and CT every 4 voxels, thus formed a dataset consisting of 262,144 samples, in which the images had a dimension of 128 for each direction. The value of each voxel in CT was normalized to range 0-1 with a uniform shift of 1000 and a denominator of 4000. For kV and DRR, we ranked all voxels value in an ascending order and normalized the values of the first 80% voxels to range 0-0.8 and the rest to range 0.8-1, thus yielding a quasi-Gaussian distribution, which was favorable by the deep neural networks. We further cropped kV and DRR images with a self-supervised bitmap based on the voxels' gradients. In training, both kV and DRR were utilized, and the encoder was encouraged to learn the same feature maps for kV images and its corresponding DRR images with mean-absolute-error (MAE) as the similarity loss. Then the decoder would reconstruct the 3D CT image from the feature maps of the kV images with the CT-on-rails as ground-truth (gCT) and MAE as the reconstruction loss. In testing, only independent kV images were used. The full-size synthetic CT (sCT) was achieved by concatenating the sCTs generated by the model according to their spatial information. The image quality of the sCT was evaluated using MAE and per-voxel-absolute-CT-number-difference volume histogram (CDVH). The proposed network was implemented with PyTorch deep learning library and both distributed data parallel (DDP) and automatic mixed precision (AMP) were applied to saving memory and accelerating the training speed. We used the AdamW optimizer with β1 = 0.9 and β2 = 0.999 and a cosine annealing learning rate scheduler with an initial learning of 1e-7 and 20 warm-up epochs.

RESULTS

The model achieved a MAE of <40HU and the CDVH showed that <5% of the voxels had a per-voxel-absolute-CT-number-difference larger than 185HU. The profile of a typical gCT slice and its corresponding sCT slice exhibited a high agreement, indicating the high similarity between the gCT and sCT.

CONCLUSION

A patient-specific vision-transformer-based network was developed and shown to be accurate and efficient to reconstruct 3D CT images from kV images.

Evaluating the effects of minimum unit pricing in Scotland on the prevalence of harmful drinking: a controlled interrupted time series analysis

OBJECTIVES

In May 2018, the Scottish Government introduced a minimum unit price (MUP) for alcohol of £0.50 (1 UK unit = 8 g ethanol) to reduce alcohol consumption, particularly among people drinking at harmful levels. This study aimed to evaluate MUP's impact on the prevalence of harmful drinking among adults in Scotland.

STUDY DESIGN

This was a controlled interrupted monthly time series analysis of repeat cross-sectional data collected via 1-week drinking diaries from adult drinkers in Scotland (N = 38,674) and Northern England (N = 71,687) between January 2009 and February 2020.

METHODS

The primary outcome was the proportion of drinkers consuming at harmful levels (>50 [men] or >35 [women] units in diary week). The secondary outcomes included the proportion of drinkers consuming at hazardous (≥14-50 [men] or ≥14-35 [women] units) and moderate (<14 units) levels and measures of beverage preferences and drinking patterns. Analyses also examined the prevalence of harmful drinking in key subgroups.

RESULTS

There was no significant change in the proportion of drinkers consuming at harmful levels (β = +0.6 percentage points; 95% confidence interval [CI] = -1.1, +2.3) or moderate levels (β = +1.4 percentage points; 95% confidence interval = -1.1, +3.8) after the introduction of MUP. The proportion consuming at hazardous levels fell significantly by 3.5 percentage points (95% CI = -5.4, -1.7). There were no significant changes in other secondary outcomes or in the subgroup analyses after correction for multiple testing.

CONCLUSIONS

Introducing MUP in Scotland was not associated with reductions in the proportion of drinkers consuming at harmful levels but did reduce the prevalence of hazardous drinking. This adds to previous evidence that MUP reduced overall alcohol consumption in Scotland and consumption among those drinking above moderate levels.

Serotonin is a Common Thread Linking Different Classes of Antidepressants

Depression pathology remains elusive. The monoamine hypothesis has placed much focus on serotonin, but due to the variable clinical efficacy of monoamine reuptake inhibitors, the community is looking for alternative therapies such as ketamine (synaptic plasticity and neurogenesis theory of antidepressant action). There is evidence that different classes of antidepressants may affect serotonin levels; a notion we test here. We measure hippocampal serotonin in mice with voltammetry and study the effects of acute challenges of antidepressants. We find that pseudo-equivalent doses of these drugs similarly raise ambient serotonin levels, despite their differing pharmacodynamics because of differences in Uptake 1 and 2, rapid SERT trafficking and modulation of serotonin by histamine. These antidepressants have different pharmacodynamics but have strikingly similar effects on extracellular serotonin. Our findings suggest that serotonin is a common thread that links clinically effective antidepressants, synergizing different theories of depression (synaptic plasticity, neurogenesis and the monoamine hypothesis).

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Examination of cross-group contact at work and school in relation to acute and retrospective discrimination experiences and drinking to cope for Black and White young adult drinkers

Black drinkers experience more alcohol problems compared to White drinkers at comparable levels of alcohol use (Mulia et al., 2009; Witbrodt et al., 2014; Zapolski et al., 2014). Research has found that Black compared to White drinkers endorse drinking to cope more frequently via retrospective report (Bradizza et al., 1999; Cooper et al., 2008). Additional research is needed to understand contributors to these racial differences. The primary aim of the present study was to examine how quality and frequency of cross-group contact at work and/or school relates to experiencing discrimination and, in turn, drinking to cope. Seventy-two young adult drinkers (Mage = 25, 72% female, 28% male; 64% Black, 36% White) completed baseline questionnaires and a subset (n = 50) completed a 17-day ecological momentary assessment (EMA) protocol. Cross-group contact frequency and quality was assessed at baseline while discrimination and coping motives were assessed via retrospective report at baseline and acutely via EMA. Accounting for sociodemographic covariates, path analyses utilizing retrospective measures revealed a significant indirect pathway from race to coping motives through quality of work/school cross-group contact and discrimination experiences related to assumptions of inferiority. Identical path analyses utilizing the acute EMA data revealed a significant indirect pathway from race to coping motives through quality of work/school cross-group contact. Improving cross-group contact at work and school may reduce drinking to cope. Additional research examining multiple domains of discrimination, quality of cross-group contact, and alcohol problems over time is needed to further understanding of social determinants of health inequities in alcohol problems. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Care navigation increases initiation of hepatitis C treatment following release from prison in a prospective randomised controlled trial: The C-LINK Study

Background

Prison-based hepatitis C treatment is safe and effective; however, many individuals are released untreated due to time or resource constraints. On community re-entry, individuals face a number of immediate competing priorities, and in this context, linkage to hepatitis C care is low. Interventions targeted at improving healthcare continuity after prison release have yielded positive outcomes for other health diagnoses; however, data regarding hepatitis C transitional care are limited.

Methods

We conducted a prospective randomized controlled trial comparing a hepatitis C care navigator intervention with standard of care for individuals released from prison with untreated hepatitis C infection. The primary outcome was prescription of hepatitis C direct-acting antivirals (DAA) within 6 months of release.

Results

Forty-six participants were randomized. The median age was 36 years and 59% were male. Ninety percent (n = 36 of 40) had injected drugs within 6 months before incarceration. Twenty-two were randomized to care navigation and 24 were randomized to standard of care. Individuals randomized to the intervention were more likely to commence hepatitis C DAAs within 6 months of release (73%, n = 16 of 22 vs 33% n = 8 of 24, P < .01), and the median time between re-entry and DAA prescription was significantly shorter (21 days [interquartile range {IQR}, 11–42] vs 82 days [IQR, 44–99], P = .049).

Conclusions

Care navigation increased hepatitis C treatment uptake among untreated individuals released from prison. Public policy should support similar models of care to promote treatment in this high-risk population. Such an approach will help achieve hepatitis C elimination as a public health threat.

Voltammetric Approach for Characterizing the Biophysical and Chemical Functionality of Human Induced Pluripotent Stem Cell-Derived Serotonin Neurons

Depression is quickly becoming one of the world's most pressing public health crises, and there is an urgent need for better diagnostics and therapeutics. Behavioral models in animals and humans have not adequately addressed the diagnosis and treatment of depression, and biomarkers of mental illnesses remain ill-defined. It has been very difficult to identify biomarkers of depression because of in vivo measurement challenges. While our group has made important strides in developing in vivo tools to measure such biomarkers (e.g., serotonin) in mice using voltammetry, these tools cannot be easily applied for depression diagnosis and drug screening in humans due to the inaccessibility of the human brain. In this work, we take a chemical approach, ex vivo, to introduce a human-derived system to investigate brain serotonin. We utilize human induced pluripotent stem cells differentiated into serotonin neurons and establish a new ex vivo model of real-time serotonin neurotransmission measurements. We show that evoked serotonin release responds to stimulation intensity and tryptophan preloading, and that serotonin release and reuptake kinetics resemble those found in vivo in rodents. Finally, after selective serotonin reuptake inhibitor (SSRI) exposure, we find dose-dependent internalization of the serotonin reuptake transporters (a signature of the in vivo response to SSRI). Our new human-derived chemical model has great potential to provide an ex vivo chemical platform as a translational tool for in vivo neuropsychopharmacology.

Momentary associations between stress and alcohol craving in the naturalistic environment: differential associations for Black and White young adults

BACKGROUND AND AIMS

Black drinkers compared with White drinkers experience more alcohol-related problems. Examination of social determinants of inequities in alcohol problems is needed. The current study measured (1) associations between acute stress and alcohol craving in the naturalistic environment for self-identified Black and White individuals who drink alcohol and (2) whether a history of attention deficit hyperactivity disorder (ADHD) moderated these associations.

DESIGN AND SETTING

Observational study using ecological momentary assessment (EMA) to collect data from participants at six semi-random time-points throughout the day during a 10-day period. A series of three-level multi-level models examined between- and within-person associations for stress and alcohol and tested if these associations differed for Black and White adults.

PARTICIPANTS

Participants were 229 adult drinkers (aged 21-35 years) who completed a larger study examining alcohol response for Black and White adults with and without a history of childhood ADHD.

MEASUREMENTS

Momentary stress and alcohol craving, ADHD history and socio-demographic characteristics (i.e. racial identity, sex, age, current education level, household income) were assessed. Participants were required to self-identify as either 'African American or Black' or 'European American or White'.

FINDINGS

Significant racial identity × stress interactions indicated that associations between stress and craving were stronger for Black compared with White adults across the 10-day period (between-person: B = 0.14, P = 0.007), concurrently within a given EMA time-point (within-person: B = 0.04, P = 0.001) and prospectively from time-point to time-point (within-person: B = 0.05, P = 0.001). Results remained while accounting for income × stress interactions.

CONCLUSIONS

Acute stress appears to be more strongly related to alcohol craving in self-identified Black compared with self-identified White individuals. This provides support for policy changes to eliminate structural inequities that increase stress exposure and the development of just-in-time culturally responsive interventions focused on coping with acute stress for Black individuals.

Management of false passage complication during operative hysteroscopy

Background

False passage is a possible complication during operative hysteroscopy and can lead to termination of the intended procedure. The aim of this study is to describe two techniques to overcome the complication of false passage during operative hysteroscopy.

Results

This is a retrospective case series of 9 patients who had a false passage during operative hysteroscopy for Müllerian anomaly or endometrial polyps. The diagnosis was immediately made by visualization of a lattice network of myometrial fibers without normal landmarks of the endometrial cavity and tubal ostia. Once a false passage was suspected, an attempt was made to overcome this complication and complete the intended operative hysteroscopy. The hysteroscope was slowly withdrawn to identify both the false passage and the opening towards the internal cervical os. The hysteroscope was tilted towards the opening to the internal cervical os, and it was carefully advanced under direct vision into the endometrial cavity. In two patients, this technique failed because the opening to the internal cervical os was small, so the bridge of tissue between the internal os and false passage was partially divided using hysteroscopic scissors or a straight resectoscope loop, allowing for entry into the endometrial cavity. The intended procedures were completed successfully in all patients. No intraoperative or postoperative complications occurred as a result of the two techniques.

Conclusions

The techniques described in this study, to overcome false passage during operative hysteroscopy, appear to be safe, effective, and easy to perform. They enable the surgeon to complete the intended procedure.

Glutamate Electropolymerization on Carbon Increases Analytical Sensitivity to Dopamine and Serotonin: An Auspicious In Vivo Phenomenon in Mice?

Carbon is the material of choice for electroanalysis of biological systems, being particularly applicable to neurotransmitter analysis as carbon fiber microelectrodes (CFMs). CFMs are most often applied to dopamine detection; however, the scope of CFM analysis has rapidly expanded over the last decade with our laboratory's focus being on improving serotonin detection at CFMs, which we achieved in the past via Nafion modification. We began this present work by seeking to optimize this modification to gain increased analytical sensitivity toward serotonin under the assumption that exposure of bare carbon to the in vivo environment rapidly deteriorates analytical performance. However, we were unable to experimentally verify this assumption and found that electrodes that had been exposed to the in vivo environment were more sensitive to evoked and ambient dopamine. We hypothesized that high in vivo concentrations of ambient extracellular glutamate could polymerize with a negative charge onto CFMs and facilitate response to dopamine. We verified this polymerization electrochemically and characterized the mechanisms of deposition with micro- and nano-imaging. Importantly, we identified that the application of 1.3 V as a positive upper waveform limit is a crucial factor for facilitating glutamate polymerization, thus improving analytical performance. Critically, information gained from these dopamine studies were extended to an in vivo environment where a 2-fold increase in sensitivity to evoked serotonin was achieved. Thus, we present here the novel finding that innate aspects of the in vivo environment are auspicious for detection of dopamine and serotonin at carbon fibers, offering a solution to our goal of an improved fast-scan cyclic voltammetry serotonin detection paradigm.

Dynamic optical coherence tomography shows characteristic alterations of blood vessels in malignant melanoma

BACKGROUND

Dynamic optical coherence tomography (D-OCT) allows in vivo visualization of blood vessels in the skin and in malignant tumours. Vessel patterns in malignant melanoma may be associated with tumour stage.

OBJECTIVE

The aim of this study was to describe blood vessel patterns in melanomas and to correlate them with stage.

METHODS

One hundred fifty-nine malignant melanomas were assessed in a multicentre study. Every tumour was imaged using D-OCT prior to surgery and histologic evaluation. The tumour data such as thickness and ulceration as well as the staging at primary diagnosis and a follow-up of at least 40 months resulted in a stage classification. The vessel patterns were assessed according to predefined categories, compared with healthy adjacent skin, and correlated to stage.

RESULTS

Melanomas contained more blood vessels in different patterns compared with healthy adjacent skin. In particular, irregular vascular shapes such as blobs, coils, curves and serpiginous vessels were more common in melanomas. In addition, these patterns were significantly more often found in high-risk and metastatic melanomas than in low-risk lesions.

CONCLUSION

In melanomas, the density of the blood vessels is increased, and irregular vascular patterns are more frequent. At higher stages, especially in metastatic melanomas, these atypical vessels are significantly more common.

QOL-58. ASSESSING FATIGUE EXPERIENCED BY PEDIATRIC PATIENTS WITH INTRACRANIAL NEOPLASMS

BACKGROUND

Indiana University possessed one of the earliest clinical proton facilities in the United States. The purpose of this study was to assess fatigue and nausea/vomiting in children with central nervous system (CNS) tumors undergoing radiation therapy as part of their treatment regimen, and to understand what factors influence fatigue. DESIGN: The study was approved by the institutional review board at Indiana University and consent and/or assent from eligible participants was obtained prior to enrollment. The validated Fatigue Scale is scored on a 5-point Likert scale. Surveys were completed 1) prior to radiation therapy, 2) week three of radiation therapy, and 3) week six of radiation therapy. A score of 41 or higher for the Fatigue Scale-Parent (< 7 years), 12 or higher for the Fatigue Scale-Child (8–12 years), and 17 or higher for the Fatigue Scale-Adolescent (13–18 years), indicates significant cancer-related fatigue.

RESULTS

The study aimed to recruit a total of 50 patients during the eligible period; however, data on 31 individual participants were available for analysis. 25 patients underwent proton radiation therapy, while 6 patients underwent conventional photon therapy. The mean age of children was 8.8 years. Of the 31 patients, 22 recorded scores indicating significant cancer-related fatigue at some point during radiation therapy.

CONCLUSIONS

Cancer related fatigue continues to be a challenge, with limited understanding of factors that might predict clinically relevant fatigue This work demonstrates the feasibility of conducting symptom research for children undergoing radiation therapy; further research is needed to characterize predictors of fatigue.

Impact of Lung Parenchymal-Only Failure on Overall Survival in Early-Stage Lung Cancer Patients Treated With Stereotactic Ablative Radiotherapy

INTRODUCTION

The impact of lung parenchymal-only failure on patient survival after stereotactic ablative body radiotherapy (SABR) for early-stage non-small-cell lung cancer (NSCLC) remains unclear.

PATIENTS AND METHODS

The study population included 481 patients with early-stage NSCLC who were treated with 3- to 5-fraction SABR between 2000 and 2016. The primary study objective was to assess the impact of out-of-field lung parenchymal-only failure (OLPF) on overall survival (OS).

RESULTS

At a median follow-up of 5.9 years, the median OS was 2.7 years for all patients. Patients with OLPF did not have a significantly different OS compared to patients without failure (P = .0952, median OS 4.1 years with failure vs. 2.6 years never failure). Analysis in a 1:1 propensity score-matched cohort for Karnofsky performance status, comorbidity score, and smoking status showed no differences in OS between patients without failure and those with OLPF (P = .8). In subgroup analyses exploring the impact of time of failure on OS, patients with OLPF 6 months or more after diagnosis did not have significantly different OS compared to those without failure, when accounting for immortal time bias (P = .3, median OS 4.3 years vs. 3.5 years never failure). Only 7 patients in our data set experienced failure within 6 months of treatment, of which only 4 were confirmed to be true failures; therefore, limited data are available in our cohort on the impact of OLPF for ≤ 6 months on OS.

CONCLUSION

OLPF after SABR for early-stage NSCLC does not appear to adversely affect OS, especially if occurring at least 6 months after SABR. More studies are needed to understand if OLPF within 6 months of SABR is associated with adverse OS. These data are useful when discussing prognosis of lung parenchymal failures after initial SABR.

Exploiting tumor position differences between deep inspiration and expiration in lung stereotactic body radiation therapy planning

PURPOSE

We demonstrate proof of principle that normal tissue doses can be greatly reduced in lung stereotactic body radiation therapy (SBRT) for mobile tumors, if the delivered dose is split between opposite respiratory states.

METHODS

Patients that underwent 5 fraction lung SBRT at our institution and had deep inspiration breath hold (DIBH) and free breathing 4D computed tomography scans were included. Volumetric modulated arc therapy plans were generated on both respiratory phases and a third composite plan was generated delivering half the dose using the DIBH plan and the other half using the expiratory phase plan for each fraction. Computed tomography scans for the composite plan were fused based on ribs adjacent to the tumor to evaluate the dose volume histogram of critical structures.

RESULTS

Four patients with 4 total tumors had requisite planning scans available. Tumor size was between 0.7 to 2.9 cm and tumor movement 1.4 to 2.9 cm. Median reduction in the chest wall (CW) V30Gy for the composite plan was 74.6% (range 33.7 to 100%), 76.9% (range 32.9 to 100%), and 89.3% (range 69.5 to 100%) compared to the DIBH, expiration phase, and free breathing plans, respectively. Median reduction in CW maximum dose for the composite plan was 23.3% (range 0.27% to 46.4%), 23.5% (range 3.2 to 48.2%), and 23.4% (range 0.27% to 48.4%) compared to the DIBH, expiration phase, and free breathing plans, respectively. Greater reduction in CW maximum dose was observed when patients had no overlap in planning target volumes between DIBH and expiration phases (median reduction 43.9% for no overlap vs 2.7% with overlap). Between all plans, lung V20Gy absolute differences were within 1.3%. For 2 of 4 patients, the composite plan met constraints for 3 fraction SBRT, while standard plans did not.

CONCLUSIONS

We conclude that composite DIBH-expiration SBRT planning has the potential to improve organ at risk sparing.

Interdisciplinary working in public health research: a proposed good practice checklist

Background

Guidance on how different disciplines from the natural, behavioural and social sciences can collaborate to resolve complex public health problems is lacking. This article presents a checklist to support researchers and principle investigators to develop and implement interdisciplinary collaborations.

Methods

Fourteen individuals, representing 10 disciplines, participated in in-depth interviews to explore the strengths and challenges of working together on an interdisciplinary project to identify the determinants of substance use and gambling disorders, and to make recommendations for future interdisciplinary teams. Data were analysed thematically and a checklist was derived from insights offered by participants during interview and discussion among the authors on the implications of findings.

Results

Participants identified 18 scientific, interactional and structural strengths and challenges of interdisciplinary research. These findings were used to develop an 18-item BASICS checklist to support future interdisciplinary collaborations. The five domains of the checklist are: (i) Blueprint, (ii) Attitudes, (iii) Staffing, (iv) Interactions and (v) Core Science.

Conclusion

Interdisciplinary work has the potential to advance public health science but the numerous challenges should not be underestimated. Use of a checklist, such as BASICS, when planning and managing projects may help future collaborations to avoid some of the common pitfalls of interdisciplinary research.

Cardiovascular and renal outcomes following percutaneous coronary intervention in a population with renal disease: a case-control study

BACKGROUND

Patients with renal disease are less likely to undergo percutaneous coronary intervention (PCI) due to concerns about poor outcomes.

AIM

We describe outcomes following PCI in individuals with chronic kidney disease (CKD), as compared with matched controls with comparable CKD who did not undergo PCI. We also identified factors predictive of poor outcomes following PCI amongst patients with CKD.

DESIGN

Retrospective observational case-control study.

METHODS

Cases were individuals with CKD (stages 1-5) undergoing PCI between 2008 and 2014. Controls were age, gender and creatinine-matched individuals not requiring PCI. We compared mortality between groups using Kaplan-Meier curves and Cox regression modelling. We assessed changes in serum creatinine using Wilcoxon Rank testing. We explored the relationship between biochemical and haematological measures (baseline creatinine, calcium, phosphate, calcium-phosphate product, parathyroid hormone, white cell count, haemoglobin, platelet count, c-reactive protein and total cholesterol) and post-PCI mortality, using logistic regression.

RESULTS

We identified 144 cases and 144 controls. Mortality was significantly lower amongst cases compared with controls [hazard ratio 0.46 (95% confidence intervals 0.31, 0.69)]. PCI did not result in a significant change in renal function (P=0.52). Amongst cases, serum creatinine and calcium-phosphate product were predictors of mortality following PCI.

CONCLUSION

Cases undergoing PCI had lower mortality, and PCI was not associated with accelerated CKD progression. On this data, PCI should not be deferred as a treatment option in patients with CKD. Serum creatinine and calcium-phosphate product predict mortality following PCI in this cohort, and may be useful in risk-stratifying patients with CKD being considered for PCI.

The influence of socioeconomic status on presentation and outcome of acute kidney injury

AIM

Although socioeconomic background is known to impact on the incidence and progression of chronic kidney disease, its influence of on the presentation and outcome for acute kidney injury is not known and is the subject of this study.

DESIGN

The Welsh National electronic AKI reporting system was used to identify all cases of AKI in patients >18 years of age between March 2015 and November 2017.

METHODS

Socioeconomic classification of patients was derived from the Welsh Index Multiple Deprivation score (WIMD). Patients were grouped according to the WIMD score by their postcode, and the ranked data were categorized into percentiles and correlated with incidence and measures of AKI severity and outcome.

RESULTS

Date was collected on a total of 57 654 patients. Increased deprivation was associated with higher AKI incidence rates, more episodes of AKI per patient and more severe AKI at presentation. In contrast 90-day mortality was highest in the most affluent areas. Mortality in affluent areas was driven by increased patient age. Corrected for age 90-day mortality was higher in areas of increased deprivation.

CONCLUSION

This study highlights that AKI incidence presentation and outcomes are adversely affected by social deprivation. Further studies are required to understand the extent to which these differences reflect patient related factors or regional differences in provision and access to care.

Single arm two-stage studies: Improved designs for molecularly targeted agents

Mechanistic understanding of cancers and their potential interactions with molecularly targeted agents is driving the need for stratified medicine to ensure each participant receives the best possible care. This understanding, backed by scientific research, should be used to guide the design of clinical trials for these agents. The mechanism of action of a molecularly targeted agent often suggests that a biomarker can be used as a predictor of activity of the agent on the targeted disease. A biomarker driven trial is needed to confirm that the molecularly targeted agent stratifies the participant population with disease into high and low responder groups. We assume that the biomarker of interest can be dichotomised and propose a balanced parallel two-stage single-arm phase II trial that builds on existing two-stage single-arm designs. A single-arm trial cannot distinguish between a marker being predictive in the population as a whole and the agent causing an increased response in the marker positive group, but it is a first step. We compare this approach to the existing single-arm approaches, sequential enrichment, tandem two-stage, and parallel two-stage designs, and discuss the advantages and disadvantages of each design. We show that our design compares favourably to existing designs in the Bayesian framework, making a more efficient use of collected data. We recommend using the parallel two-stage balanced or sequential enrichment designs when randomisation is not practical in a phase II trial.

Adding a new dimension to the weekend effect: an analysis of a national data set of electronic AKI alerts

BACKGROUND

Increased mortality related to differences in delivery of weekend clinical care is the subject of much debate.

AIM

We compared mortality following detection of acute kidney injury (AKI) on week and weekend days across community and hospital settings.

DESIGN

A prospective national cohort study, with AKI identified using the Welsh National electronic AKI reporting system.

METHODS

Data were collected on outcome for all cases of adult AKI in Wales between 1 November 2013 and 31 January 2017.

RESULTS

There were a total of 107 298 episodes. Weekday detection of AKI was associated with 28.8% (26 439); 90-day mortality compared to 90-day mortality of 31.9% (4551) for AKI detected on weekdays (RR: 1.11, 95% CI: 1.08-1.14, P < 0.001, HR: 1.16 95% CI: 1.12-1.20, P < 0.001). There was no 'weekend effect' for mortality associated with hospital-acquired AKI. Weekday detection of community-acquired AKI (CA-AKI) was associated with a 22.6% (10 356) mortality compared with weekend detection of CA-AKI, which was associated with a 28.6% (1619) mortality (RR: 1.26, 95% CI: 1.21-1.32, P < 0.001, HR: 1.34, 95%CI: 1.28-1.42, P < 0.001). The excess mortality in weekend CA-AKI was driven by CA-AKI detected at the weekend that was not admitted to hospital compared with CA-AKI detected on weekdays which was admitted to hospital (34.5% vs. 19.1%, RR: 1.8, 95% CI: 1.69-1.91, P < 0.001, HR: 2.03, 95% CI: 1.88-2.19, P < 0.001).

CONCLUSION

'Weekend effect' in AKI relates to access to in-patient care for patients presenting predominantly to hospital emergency departments with AKI at the weekend.

Dependence of Retinopathy (and other Complications) on Glycaemic Control and on Weight over 5/10 Years from Diagnosis of Type II Diabetes

Glycosylated haemoglobins and weights were recorded for 200 consecutive diabetic clinic attendere seen yearly for 5 years, 76 of whom were also seen up to 10 years from diagnosis of type 2 diabetes, representing 1380 patient years. Weight fluctuation (≥3 kg) was associated with increased final prevalence of hypertension, macroalbuminaemia and a raised creatinine (P≤ 0.002) but this relationship was abolished by correction for higher initial weight. Average giycaemia over 5/10 years [itself related to initial weight in women on tablets (N=53) but not others, and to waist but not waist/hip ratio], correlated with prevalence and severity of retinopathy (N=200; r=0.38, P≤0.0006) seen also in the subgroup of patients on tablets (N=145, P≤0.006). At HbA1 levels ≥10.5% an increased prevelance of retinopathy was seen in those on insulin (W=37, P≤0.001) and an increased prevalence of peripheral vascular disease was seen in men but not women (x2=2.87, P≤0.01) as well as in the prevalence of neuropathy. These findings suggest that good glycaemic control is of value in type 2 diabetes and less easily achieved in obesity.

Prospective study of the feasibility of point-of-care testing strategy for carbapenem-resistant organism detection

BACKGROUND/AIMS

 In an investigator-initiated, prospective study, we evaluated the feasibility of a five-gene sequence point-of-care (POC) testing strategy (Xpert CARBA-R Assay, Cepheid Inc., Sunnyvale, CA, USA), compared to reference laboratory PCR (48 - 72 hours turnaround time, two gene sequences), in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and in a hospital outbreak investigation.

METHODS

 After informed consent, patients undergoing ERCP (September 2015 - April 2016, n = 191) at Mayo Clinic and potential hospital contacts (n = 9) of an index carbapenem-resistant organism (CRO)-positive inpatient were included. Two rectal swabs, one each for reference and POC assays were obtained. The Xpert CARBA-R Assay enables qualitative rapid detection of five beta-lactamase gene sequences associated with carbapenem-non-susceptibility in Gram-negative bacteria. Feasibility parameters (specimen processing and assay run time, ease of use) and percent agreement between the tests were calculated using JMP Pro11 (SAS Corp, Cary, NC, USA).

RESULTS

 Mean age was 62 ± 15 years; 108 (54 %) were male. Both tests were successfully performed in all patients. The POC test was rated by endoscopy nurses as easy/very easy to conduct in 193 patients (97 %); median assay run time and median time for specimen collection and processing were 55 minutes (interquartile range IQR: 53 - 55 minutes) and 3 minutes (IQR: 3 - 6 minutes), respectively. In 200/201 (99.5 %) tests, there was agreement between the POC and reference PCR.

CONCLUSIONS

 The more comprehensive POC CRO testing of patients in the endoscopy suite is feasible and results are available in < 1 hour. This strategy may enable rapid risk stratification of duodenoscope exposure to CRO and potentially improve operational efficiency and decrease costs.

Community acquired acute kidney injury: findings from a large population cohort

BACKGROUND

The extent of patient contact with medical services prior to development of community acquired-acute kidney injury (CA-AKI)is unknown.

AIM

We examined the relationship between incident CA-AKI alerts, previous contact with hospital or primary care and clinical outcomes.

DESIGN

A prospective national cohort study of all electronic AKIalerts representing adult CA-AKI.

METHODS

Data were collected for all cases of adult (≥18 years of age) CA-AKI in Wales between 1 November 2013 and 31 January 2017.

RESULTS

There were a total of 50 560 incident CA-AKI alerts. In 46.8% there was a measurement of renal function in the 30 days prior to the AKI alert. In this group, in 63.8% this was in a hospital setting, of which 37.6% were as an inpatient and 37.5% in Accident and Emergency. Progression of AKI to a higher AKI stage (13.1 vs. 9.8%, P < 0.001) (or for AKI 3 an increase of > 50% from the creatinine value generating the alert), the proportion of patients admitted to Intensive Care (5.5 vs. 4.9%, P = 0.001) and 90-day mortality (27.2 vs. 18.5%, P < 0.001) was significantly higher for patients with a recent test. 90-day mortality was highest for patients with a recent test taken in an inpatient setting prior to CA-AKI (30.9%).

CONCLUSION

Almost half of all patients presenting with CA-AKI are already known to medical services, the majority of which have had recent measurement of renal function in a hospital setting, suggesting that AKI for at least some of these may potentially be predictable and/or avoidable.

Optical coherence tomography for margin definition of basal cell carcinoma before micrographic surgery-recommendations regarding the marking and scanning technique

BACKGROUND/PURPOSE

Mohs Micrographic Surgery (MMS) is the preferred therapeutic treatment for high-risk basal cell carcinoma (BCC). Optical Coherence Tomography (OCT) is a non-invasive imaging technique that enables the diagnosis of BCC. We thought to determine the margins of BCCs with OCT, prior to MMS, to reduce the number of surgical steps.

METHODS

Different permanent markers were tested on the skin regarding line width, resistance against disinfection and brightness in the OCT image. The visible tumor margins of BCCs were defined by dermoscopy, adding a safety margin of 2 mm and labeled using the selected pen, causing a signal shadow in OCT. Scans of the center and of entire margin were performed. If parts of the BCC were visible outside the margin, another 2 mm were added and the scan was repeated until the tissue outside the labeling looked tumor free.

RESULTS

Eight out of ten BCCs were totally excised in a single stage when margin delineation was done by OCT. Macroscopic margins were enlarged after OCT scanning in four patients, saving further stages of MMS.

CONCLUSION

OCT may help to better define the microscopic dimensions of BCCs and therefore reduce the number of stages of MMS.

Acute kidney injury electronic alerts in primary care - findings from a large population cohort

BACKGROUND

Electronic reporting of AKI has been used to aid early AKI recognition although its relevance to CA-AKI and primary care has not been described.

AIMS

We described the characteristics and clinical outcomes of patients with CA-AKI, and AKI identified in primary care (PC-AKI) through AKI e-Alerts.

DESIGN

A prospective national cohort study was undertaken to collect data on all e-alerts representing adult CA-AKI.

METHOD

The study utilized the biochemistry based AKI electronic (e)-alert system that is established across the Welsh National Health Service.

RESULTS

28.8% of the 22 723 CA-AKI e-alerts were classified as PC-AKI. Ninety-day mortality was 24.0% and lower for PC-AKI vs. non-primary care (non-PC) CA-AKI. Hospitalization was 22.3% for PC-AKI and associated with greater disease severity, higher mortality, but better renal outcomes (non-recovery: 18.1% vs. 21.6%; progression of pre-existing CKD: 40.5% vs. 58.3%). 49.1% of PC-AKI had a repeat test within 7 days, 42.5% between 7 and 90 days, and 8.4% was not repeated within 90 days. There was significantly more non-recovery (24.0% vs. 17.9%) and progression of pre-existing CKD (63.3% vs. 47.0%) in patients with late repeated measurement of renal function compared to those with early repeated measurement of renal function.

CONCLUSION

The data demonstrate the clinical utility of AKI e-alerts in primary care. We recommend that a clinical review, or referral together with a repeat measurement of renal function within 7 days should be considered an appropriate response to AKI e-alerts in primary care.

Proceedings of the 12th International Conference on Rapid Response Systems and Medical Emergency Teams

Rapid Response Teams (RRTs) have been introduced into hospitals worldwide in an effort to improve the outcomes of deteriorating hospitalised patients. Recently, there has been increased awareness of the need to develop systems other than RRTs for deteriorating patients. In May 2016, the 12th International Conference on Rapid Response Systems and Medical Emergency Teams was held in Melbourne. This represented a collaboration between the newly constituted International Society for Rapid Response Systems (iSRRS) and the Australian and New Zealand Intensive Care Society. The conference program included broad ranging presentations related to general clinical deterioration in the acute care setting, as well as deterioration in the emergency department, during pregnancy, in the paediatric setting, and deterioration in mental health status. This article briefly summarises the key features of the conference, links to presentations, and the 18 abstracts of the accepted free papers.

On Contributing to the Progress of Medical Informatics as Publisher

May 1st, 2017, will mark Dieter Bergemann's 80th birthday. As Chief Executive Officer and Owner of Schattauer Publishers from 1983 to 2016, the biomedical and health informatics community owes him a great debt of gratitude. The past and present editors of Methods of Information in Medicine, the IMIA Yearbook of Medical Informatics, and Applied Clinical Informatics want to honour and thank Dieter Bergemann by providing a brief biography that emphasizes his contributions, by reviewing his critical role as an exceptionally supportive publisher for Schattauer's three biomedical and health informatics periodicals, and by sharing some personal anecdotes. Over the past 40 years, Dieter Bergemann has been an influential, if behind-the-scenes, driving force in biomedical and health informatics publications, helping to ensure success in the dissemination of our field's research and practice.